Transitional Care for Older Adults
For a senior returning home from the hospital, the course back to health can be a nightmare. Family caregivers are also at risk. Health Research for Action's hospital-to-home study revealed a number of transitional care problems and solutions.
Key Problems in Transitional Care
Before we could find policy-level solutions, we had to understand the problems. Here's what we found:
- A fragmented system of care, with varying and confusing eligibility requirements
- A policy and funding bias towards institutional rather than home care
- Privacy policies that limit information sharing across care settings
- Inadequate professional training for all providers, including in-home care workers
- Inadequate caregiver support by the medical and social service systems
Changing Policy
Health Research for Action identified solutions to help seniors recover at home, such as enhanced discharge planning, care coordination, staff training, and education for patients and caregivers.
We hosted a national Transitional Care Leadership Summit in partnership with the Gordon and Betty Moore Foundation and The California Endowment. We also presented our findings in local and national meetings and briefed state policymakers in California.